New drug policy too burdensome, hospices say

NEW YORK (Reuters Health) - The Centers for Medicare and
Medicaid Services met Wednesday with 30 hospice and healthcare
organizations after outcry over a new rule. The rule was
designed to help avoid duplicate payments for hospice
medications but may be having unintended consequences.

More than 40 organizations called for the rule's suspension
in a letter this week to CMS. Signed by the American Medical
Association, the American Society of Clinical Oncology and the
American Geriatrics Society, it argues the policy places "undue
burden" on beneficiaries - requiring "dying patients to navigate
payer disputes."

Under the new rule, CMS now requires a prior authorization
process for hospices and Part D providers to determine
responsibility of drug coverage, and hospices must cover
medications not related to the hospice diagnosis.

The Office of the Inspector General recommended the policy
to minimize mistakes in which Part D plans covered hospice
drugs, but many hospice providers say they now face financial
burdens that are not theirs to bear.

National Hospice and Palliative Care Organization President
Don Schumacher calls it a "ridiculous regulation," as the
average daily Medicare hospice reimbursement is $160. "The
margins are very low," Schumacher said, and hospices don't "have
extra cash to spend on drugs we're not supposed to be paying
for."

CMS did not reply to Reuters Health's inquiries about
opposition, sending instead a memo detailing the rule for Part D
plans and hospices.

More than a month after the rule's effective date, many
hospices are also strained in administrative capacity. "When
you're talking about prior authorization, you're talking about
something that is going to delay services," said Theresa
Forester of the National Organization for Home Care and Hospice.
The answer to how hospices and patients will manage these delays
is unfolding.

At Journeycare, a hospice serving 500 patients daily across
northern Illinois, the duration of admissions visits has
lengthened. Case managers spend longer in homes, communicating
with Part D plans proactively. "We are trying to eliminate
families having to deal with denials and appeals," said Penny
Murphy, Vice President of Compliance and Quality.

"In the past, we might have allowed patients to continue a
medication rather than engage in a negotiation," Twaddle said.
"Now, some hospices will be forced to be more forthright in
stopping medications not shown to be helpful."

Statins for high cholesterol and medications to slow
osteoporosis and dementia are examples of those unnecessary for
hospice patients, Twaddle said. Others - to treat certain lung
diseases, for example, in advanced cancer patients - can enhance
overall comfort, although they are unrelated to the terminal
diagnosis.

"Some hospices may substitute less expensive medications
that are not as effective, and you don't want to be monkeying
around when someone is dying," Twaddle said.

However, Journeycare reports having enough capacity to
manage the change. "There are many programs that do not, and I
have a very strong concern for them," Murphy said.

Angels Grace Hospice, located 40 miles from JourneyCare in
Chicago's southwest suburbs, may be among them. Serving 45
patients daily, the hospice reports a 30 percent uptick in drug
costs. "We're still navigating it," said Chief Financial Officer
Greg Zrazik. "We've taken the position that we cover all drugs
while we assess the situation. It's a fairly liberal,
compassionate approach."

Dr. Robert Arnold, of the University of Pittsburgh Center
for Bioethics and Health Law, says the rule unfairly places the
onus of larger healthcare problems on hospices that weren't
involved in putting patients on these medications in the first
place.

"It's making hospice even more of the bad guy," Arnold said,
explaining the rule could make decisions to receive hospice care
harder. "There's this view of hospice, to a certain extent, that
it's tied to dying. It makes it hard for patients, even though
they say they want support hospice gives."

Hospice advocates say they are pleased CMS heard concerns
but received no indication the rule may be amended - to the
detriment of providers and patients.

"I think of the amount of questions and decisions that
families already have to make, and this is just one more thing
for a family in stress to be sorting through," Twaddle said.

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